Gheens Science Hall & Rauch Planetarium

Name of person filling out application

Email Address

I am a UofL staff, faculty or student (Note: UofL ID must be presented first day of camp when dropping off your child)

Are you already a Gheens Science Hall & Rauch Planetarium Member?

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Please let us know how you heard about our Summer Camps.

Sign up for a membership if you wish to become a member and receive discounts on workshops and camps as well as free admission to regular planetarium shows.

Camp/Session Choices

Parent/Guardian Information

Parent/Guardian 1 Information

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Street Address 2 [optional]

City

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Parent/Guardian 2 Information [optional]

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Last Name

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Street Address 1

Street Address 2 [optional]

City

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Additional Authorized Pick-Up Information [optional]

Contact/Pick-Up 1 Information

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Relationship

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Contact/Pick-Up 2 Information

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Physician/Insurance Information

Name of Family Physician

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Insurance Carrier

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Summer Camp Registration

Camp/Session Choices

Child 1

Child Information

Child 1 Information

Health Information

Child 2

Child 2 Information

Health Information

Parent/Guardian Information

Parent/Guardian 1 Information

Parent/Guardian 2 Information [optional]

Additional Authorized Pick-Up Information [optional]

Contact/Pick-Up 1 Information

Contact/Pick-Up 2 Information

Physician/Insurance Information